National Health Programmes for TB control in India

Dr Jyoti Prasad Pattnaik
MBBS, PGDMCH, PGDHM
Asst Professor
National Health
Programmes
for TB control
in India
1
Dr Jyoti Prasad Pattnaik, MBBS

Since independence in 1947
many measures have been taken to
improve the health of the people and
the society at large and the most
effective of all these programmes is
National health Programmes.
2

National Health Programmes
These programmes are launched by the central
government from time to time
• To control/eradicate communicable diseases
• Improve environmental sanitation
• Raising the standards of nutrition
• Control of population
• Improving rural health scenario
3

International Assistance
• International agencies like WHO,
UNICEF, UNFPA, World Bank
• Foreign aid agencies like SIDA, DANIDA,
NORAD, USAID etc have been providing
technical and material assistance in the
implementation of these programmes.
4

Some programmes list…
• Integrated disease surveillance programme
• National leprosy eradication programme
• National tuberculosis programme
• Revised national tb control programme
• National mental health programme
• National AIDS control programme
• National programme for prevention and control of deafness
• Universal immunization programme
• National programme for control of blindness
• Pulse polio programme
5

TB in India
TB has existed in India for several thousand years.
TB in India around 1500 BCE
• TB in India is an ancient disease. In Indian literature
there are passages from around 1500 BCE in which
consumption is mentioned, and the disease is
attributed to excessive fatigue, worries, hunger,
pregnancy and chest wounds.
Dr Jyoti Prasad Pattnaik, MBBS 6

TB in India around 500 BCE
Then from around 500 BCE there are a number of
Sanskrit manuscripts which are the texts from which the
Ayurveda system of general Indian medical practice is
derived. In at least one of these there is a group of
diseases referred to as Sosha.
These are diseases with a prominent feature of
wasting, and there are other symptoms such as “cough
and blood-spitting”. It is also said that the Moon-god, the
king of the Brahmanas was the first to become a victim of
this disease, which is as a result also known as
Rajayakshma, or king’s disease.

TB in India around 900 CE
• A subsequent important compendium on Indian medicine is the
Rogaviniscaya, usually referred to as the Madhavanidana, and
one of a number of commentaries on it is the Madhukosa. Neither
the date of the Madhavanidana or the Madhukosa is absolutely
clear but both are likely to have been written around 800 - 1000
CE.
• The Madhukosa describes the disease referred to in a number of
different texts as yaksman, consumption or rajayaksman (kingly
consumption) and it also refers to how it has been identified by
many as being what is in the twenty first century called
Tuberculosis. However, the Madhukosa also says that the texts
are clear that the ancient disease had a much wider range than
TB, and covers a number of conditions between physical
exhaustion through to cachexia or physical wasting.

Indian Research Fund Association
The Indian Research Fund Association was created by the Government of India
in 1911. A sum of 5 lakhs rupees was provided by the Government as an
endowment for research in connection with the Central Research Institute in
Kasauli.
The objects of the Association were:
(a) the cause and mode of spread of epidemic diseases;
(b) the prevention of epidemic diseases by direct attack upon the casual micro-
organisms.”
The work of the Association included the holding of an annual conference and
the publishing of its official journal, the Indian Journal of Medical Research,
which was first published in 1913. The early work of the Association did not
include significant work on Tuberculosis, because of the perceived urgent need
for work on other diseases such as Malaria, Cholera, Plague, Yellow Fever and
Leprosy.

The All-India Sanitary Conferences
• The first All-India Sanitary Conference, Bombay
1911
• The second All-India Sanitary Conference, Madras,
1912
• The third All-India Sanitary Conference, Lucknow,
1914

Tuberculosis Association of India
• In 1937 the wife of the Governor General, the Marchioness of Linlithgow
issued a public appeal, “in the name of the King Emperor” for an anti
tuberculosis fund, and nearly a crore of rupees was collected. Five per cent
of this money was retained and the balance distributed to the Provinces and
States. The Tuberculosis Association of India was formed in February 1939
using mainly the retained money. The King George V Thanksgiving Anti
Tuberculosis Fund was merged into the funds of the Tuberculosis
Association of India.
• In May 1939 Dr Frimodt Moller became the Association’s first Medical
Commissioner. During the time that he held office three major measures
were carried out by the Association. These were the establishment of the TB
clinic in New Delhi, the creation of the Lady Linlithgow Sanatorium at
Kasauli, and the formation of a scheme for organizing home treatment as an
essential part of India’s anti TB campaign.

History of TB programs in India
India has had a TB Control Program since 1962.
Since then it has re-organized itself two times; first
into the Revised National Tuberculosis Control
Program (RNTCP) in 1997 and then into the National
Tuberculosis Elimination program in 2020.

National TB Program- NTP (1962-1997)
• TB control efforts got organized with the National TB program
(NTP) primarily focusing on BCG vaccinations as a
preventive measure.
• At that time, the Indian government lacked the financial
backing to meet its public health goals. Therefore, external
sources of funding and administration, often from the WHO
and UN, became common in the realm of public health. In
1992, the WHO and Swedish International Development
Agency evaluated the NTCP, finding that it lacked funding,
information on health outcomes, consistency across
management and treatment regimens, and efficient
diagnostic techniques.

National Tuberculosis Control Program
• In 1962, the government of India launched a
National Tuberculosis Control Program to
detect as many tuberculosis cases as possible,
provide effective treatment, establish district
tuberculosis centers, extend short-course
chemotherapy, and strengthen existing state
tuberculosis training and demonstration
centers.

A 1992 review of the national program revealed
inadequate budgetary outlays and drug shortages, an
overemphasis on clinical and radiologic diagnosis,
insufficient utilization of sputum microscopy facilities, an
emphasis on case detection rather than cure, and a lack
of consensus on treatment regimens. On the basis of
these findings, the national strategy has been revised to
achieve an 85% cure rate through administration of short-
course (6-8 months) chemotherapy and to detect 70% of
estimated cases.

Strategies for achieving these objectives include use
of sputum testing as the primary diagnostic method
among self-referred cases, a standardized treatment
regimen, an uninterrupted supply of drugs at all levels
of the health system, increased budgetary outlays,
creation of a sub-district supervisory unit, and greater
emphasis on training and operations research.

Revised National TB Control
Program- RNTCP (1997-2020)
• The large scale implementation of the Indian
government’s Revised National TB Control Program
(RNTCP) (sometimes known as RNTCP 1) was started
in 1997. The RNTCP was then expanded across India
until the entire nation was covered by the RNTCP in
March 2006. At this time the RNTCP also became
known as RNTCP II. RNTCP II was designed to
consolidate the gains achieved in RNTCP I, and to
initiate services to address TB/HIV, MDR-TB and to
extend RNTCP to the private sector.

RNTCP in India
• RNTCP uses the World Health Organisation (WHO)
recommended Directly Observed Treatment Short
Course (DOTS) strategy and reaches over a billion
people in 632 districts/reporting units. The RNTCP is
responsible for carrying out the Government of India
five year TB National Strategic Plans.
• With the RNTCP both diagnosis and treatment of TB
are free. There is also, at least in theory, no waiting
period for patients seeking treatment and TB drugs.

RNTCP in India
The initial objectives of the RNTCP in India were:
• to achieve and maintain a TB treatment success rate of at
least 85% among new sputum positive (NSP) patients.
• to achieve and maintain detection of at least 70% of the
estimated new sputum positive people in the community.
New sputum positive patients are those people who have never
received TB treatment before, or who have taken TB drugs for
less than a month. They have also had a positive result to a
sputum test, which diagnoses them as having TB

National Tuberculosis Elimination
Program, RNTCP
• RNTCP renamed as NTEP
• At the start of 2020 the central government
renamed the RNTCP the National Tuberculosis
Elimination Program (NTEP). In a lettter to all the
State Chief Secretaries of states and UTs, the
commitment is emphasised of the Union
government achieving the sustainable development
goal of ending TB by 2025, five years ahead of the
global targets.

National Tuberculosis Elimination
Program (NTEP)
The National Tuberculosis Elimination Program (NTEP) is
the Public Health initiative of the Government of India that
organizes its anti-Tuberculosis efforts. It functions as a
flagship component of the National Health Mission (NHM)
and provides technical and managerial leadership to anti-
tuberculosis activities in the country. As per the National
Strategic Plan 2012–17, the program has a vision of
achieving a "TB free India", and aims to provide Universal
Access to TB control services. The program provides,
various free of cost, quality tuberculosis diagnosis and
treatment services across the country through the
government health system.

India National Strategic Plan (NSP)
for TB 2017 - 2025
• The Indian TB National Strategic Plan (NSP) 2017 - 2025 is
the plan produced by the government of India (GoI) which
sets out what the government believes is needed to eliminate
TB in India. The NSP 2017 - 2025 describes the activities and
interventions that the GoI believes will bring about significant
change in the incidence, prevalence and mortality from TB.
This is in addition to what is already going on in the country.
• The NSP sets out the recommendations of the GoI. However,
the rate at which these recommendations are implemented,
will largely depend on the action taken by individual states.
The state of Uttar Pradesh has the highest number of TB
patients notified by both the public and private sector.

Visions & Goals of the National
Strategic Plan
• The Vision is of a TB free India with zero deaths,
disease and poverty due to tuberculosis
• The Goal is to achieve a rapid decline in the burden of
TB, mortality and morbidity, while working towards the
elimination of TB in India by 2025.
• The requirements for moving towards TB elimination in
India have been arranged in four strategic areas of
• Detect, Treat, Prevent & Build.There is also across all
four areas, an overarching theme of the Private Sector.
Another overarching theme is that of Key Populations.

Targets
The targets of the National Strategic Plan are set out as
consisting of both outcome and impact indicators. There are
also four main “thrust” or priority areas in the NSP which are:
• Private sector engagement;
• Plugging the “leak” from the TB care cascade (i.e. people with
TB going missing from care);
• Active case finding among key populations;
• and for people in “high risk” groups, preventing the
development of active TB in people with latent TB.
• Another “thrust” area is that of the Programmatic
Management of Drug Resistant TB (PMDT).

Detect
The aim is to detect all those people with drug sensitive
TB as well as those with drug resistant TB. The emphasis
is to be on reaching TB patients seeking care from private
providers and also finding people with undiagnosed TB in
“high risk” or key populations. This is to be done through:
• Scaling up free, high sensitivity TB diagnostic tests
such as CBNAAT;
• Scaling up private provider engagement approaches;
• Universal testing for drug resistant TB;
• & Systematic screening of high risk populations.

Diagnosis
• The Technical & Operational Guidelines for TB
Control (TOG) describes how various tests should
be used to diagnose anyone who has signs and
symptoms suggesting that they might have TB. The
tests to be used are sputum smear microscopy,
chest X ray and the new CB-NAAT test. The CB-
NAAT test is beginning to be made available
throughout India. There is a diagram, or set of rules,
which shows which tests should be used for
different groups of people.

Active case finding
• The main objective of active case finding (ACF) is to
detect TB cases early and to initiate treatment
promptly. The NSP emphasizes the need to shift
from passive case finding, which is waiting for
people to seek care, to ACF which involves seeking
out people in targeted groups.
• In Karnataka 1,150 cases of TB were identified in
just the first week of active case finding.

Treatment
Initiate and sustain all patients on appropriate anti-tb treatment wherever they
seek care. Provide patient friendly systems and social support. This is to be
done through:
• Preventing the loss of TB cases in the cascade of care by providing support
systems. The “cascade of care” means every step in the provision of
treatment, from when it is first started, to the point at which the patient
finishes their treatment and is cured of TB;
• Providing free TB drugs for all patients with TB;
• Provide daily TB drugs for all patients with TB and a rapid scale up of short
course regimens for drug resistant TB. Provide treatment approaches
guided by drug sensitivity testing.
• Providing patient friendly adherence monitoring and social support in order
to sustain TB treatment;
• & The elimination of catastrophic costs by linking eligible TB patients with
social welfare schemes including providing nutritional support.

Nutritional support
• It has now been announced that patients with TB will
receive R500 ($8) a month for food. There is more
about all the Direct Benefit Transfer schemes for TB.
• Under nutrition is a risk factor for TB in India. Under
nutrition worsens the nutritional status, generating a
vicious cycle which can lead to adverse outcomes
during and after treatment for patients with active TB.
This includes those with MDR-TB. So this payment is
partially to ensure that patients with TB have adequate
food. There is more about food and TB and nutrition &
TB.

Prevention
Preventing the emergence of TB in susceptible
populations. This is to be done through
• Scaling up air-borne infection control measures at
health care facilities;
• Providing treatment for latent TB infection for the
contacts of people with confirmed TB;
• & Addressing the social determinants of TB through an
approach across different sectors. The social
determinants of health are generally considered to be
the conditions in which people live and work that affect
their health.

Build
Build and strengthen relevant policies. Provide extra capacity for
institutions and extra human resources capacity. This is to be
done through:
• Translating high level political commitment into action;
• Restructuring the RNTCP and other institutional
arrangements;
• Building supportive structures for surveillance, research and
innovations. Providing a range of interventions based on the
local situation;
• Scaling up technical assistance at national and state levels;
• & Preventing the duplication of partners’ activities

Private provider engagement
• At least half of those treated for TB in India first attend the
largely unorganized and unregulated private sector. Patients
from low income households will often lose several months of
their income in the process of paying for inappropriate
diagnostics and treatments before starting approved therapy.
• Patients treated by private providers have often not been
notified to the RNTCP, despite government orders to that
effect. Patients cared for by private providers rarely receive
sputum testing, and DST. Similarly, public health services
such as surveillance, adherence monitoring, contact
investigation, and outcome recording rarely reach privately
treated patients.

National Strategic Plan To End TB in
India 2020-25
This NSP is an update of the NSP 2017 2025 which is necessitated by the rapidly
changing environment within which NTEP operates. Knowledge and insights generated
from the Joint Monitoring mission in 2019, 16 large scale programme evaluations
(Central Internal Evaluations) during 2017-2019; implementation of the past NSP
especially scale up of private sector involvement strategies, roll out of rapid molecular
tests, LTBI treatment rollout; and updated recommendations from WHO sets the
direction for this NSP. As in the past, the NSP 2020 2025 is a framework to guide the
activities of all stakeholders including the national and state governments, development
partners, civil society organizations, international agencies, research institutions,
private sector, and many others whose work is relevant to TB elimination in India. This
NSP is a five year strategy document that provides goals, strategies and interventions
for the country’s response to the disease and aims to direct the attention of all
stakeholders to the most important interventions that the NTEP believes will bring
about significant changes in the incidence, prevalence and mortality of TB. These
strategies and interventions are in addition to the processes and activities already
ongoing in the country.

Dr Jyoti Prasad Pattanayak
MBBS, PGDMCH, PGDHM
Asst Professor
Dept of Pharmacology
Roland Institute of Pharmaceutical Sciences
Khodasingi, Berhampur, 760010, Odisha
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National Health Programmes for TB control in India

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